Commentary
Helping patients with addictions get, stay clean
Advise patients to consider programs affiliated with major medical centers or established treatment centers, an expert says.
SAN DIEGO – Intervening early can positively affect outcomes for patients struggling with substance use disorders, regardless of their current stage of development and place in the life cycle, speaker after speaker said at the annual meeting and scientific symposium of the American Academy of Addiction Psychiatry.
The prenatal/perinatal period represents a high-risk window for the kindling and precipitation of substance use disorders (SUDs), because of the stress of pregnancy, delivery, recovery, and the newly assumed parenting role. “Offspring who are exposed in utero have an earlier age of initiation of substance use, as well as a greater risk of substance use disorders later on in life,” said Justine Wittenaur Welsh, MD, director of the Emory Adolescent Substance Use Treatment Services, Atlanta. “We as treatment providers need to start to think about how to screen for these individuals. What types of early intervention can we provide, and how do we integrate this into our treatment planning?”
According to data on current illicit drug use among pregnant women from the Substance Abuse and Mental Health Services Administration, the risk is highest among those aged 15-17 years (14.6%), followed by those aged 18-25 years (8.6%), and 26-44 years (3.2%). “We also know that rates of substance use are higher in the first trimester, compared with the second and the third,” said Dr. Welsh, who holds a faculty position in the department of psychiatry and behavioral sciences at Emory University. “But unfortunately, a significant number of pregnant women return to substance use after they deliver. This is really important for treatment providers, to intervene early before a return to substance use. We know that improving the postnatal environment does reduce the risk of substance use, even in individuals who have in utero exposures.”
Dr. Justine Wittenaur Welsh
SUDs confer a host of adverse effects to both the baby and the mother. “With tobacco, although there are a significant number of poisonous chemicals in cigarettes that the baby would be exposed to, we believe it’s the carbon monoxide and the nicotine exposure that confers the most known damage,” Dr. Welsh said. In utero exposure to cigarettes increases the likelihood to initiate smoking during adolescence by twofold (Neurotoxicol Teratol. 2005;27[2]:267-77), and a dose-response relationship has been observed between prenatal smoking and psychiatric hospitalization for substance abuse in offspring (Am J Psychiatry. 2002;159[1]:48-54). In utero exposure to cigarettes also increases the risk for offspring cigarette use. “The exposure to greater than a half-pack of cigarettes per day has a 5.5-fold increased risk for early cigarette experimentation, while exposure to one pack per day or more is associated with twice the risk of developing nicotine dependence,” she said.
As for in utero alcohol exposure, consuming greater than or equal to three drinks is associated with an alcohol disorder at age 21 (odds ratio, 2.95) if the exposure occurred in early pregnancy; Arch Gen Psychiatry. 2006;63[9]:1009-16). In utero alcohol exposure also has been more predictive of adolescent alcohol use than family history. “It’s also been associated with an increased number of abuse/dependency symptoms in offspring, for nicotine, alcohol, and illicit drugs,” Dr. Welsh said. “It has also been associated with an increased risk of cigarette use and substance use disorders in offspring.”
In utero cannabis exposure has been associated with a twofold increased risk of tobacco and marijuana use later in life (Addiction 2006;101[9]:1313-22), as well as with a twofold increased risk of smoking cigarettes daily and of using marijuana during adolescence. In utero cocaine exposure has been associated with a twofold increased risk of using tobacco, a 2.2-fold increased risk of using alcohol, and a 1.8-fold risk of using marijuana, as well as a 2.1-fold increased risk of having an SUD by age 17. “Prenatal exposure and postnatal parent/caregiver cocaine use is uniquely related to teen use of cocaine at age 14,” Dr. Welsh said. “In addition, exposure in the first trimester is associated with earlier marijuana and alcohol initiation.”
Real-world barriers to SUD treatment in adolescents include a lack of coordination between treatment resources, fear of losing custody of children, shame and stigma, concerns about criminal prosecution, domestic violence, and other obstacles such as transportation, finances, and child care. Dr. Welsh pointed out that pregnant women with SUDs usually receive prenatal care and addiction treatment from different providers. “We should be thinking about an integrated treatment model to improve maternal and prenatal care for patients using substances prior to or during pregnancy,” she said. “Some sites have developed combined maternity care units as a way to reduce some of these barriers to treatment. We also need to be thinking about the infants themselves. In order to counter the drug-exposed child’s early disadvantages, service providers must be prepared to intervene early, focusing on things like nutrition, psychomotor assessments, early educational needs assessments, as well as modification of existing treatment services for people with in utero exposures. This can be a difficult population to treat.”
One resource for addressing fetal alcohol spectrum disorders that she recommended is Treatment Improvement Protocol 58, published by Substance Abuse and Mental Health Services Administration. She described one young adult with significant substance use issues who was diagnosed with fetal alcohol syndrome as a child. “This young adult didn’t know about the FAS diagnosis,” Dr. Welsh said. “I expressed to the mother that, ‘this is an ethical dilemma. I’m treating someone and I know this directly impacts my treatment planning. They have a real-world diagnosis that I feel they have a right to know about.’ It made me think: If I think it’s so important that this young adult knows the diagnosis, why are we not screening for it in our general patient populations more often?
“As child psychiatrists we often ask, ‘Were there any in utero exposures?’ When treating adults, I’m asking about family history, but I’m not asking about in utero exposures. This may not be information that they’re privy to, but it’s worth starting a conversation about.”
, a 14-session, evidence-based curriculum that addresses parenting skills, children’s social skills, and family life skills training, are among the treatment options aimed at decreasing the risk of substance use progression in offspring.